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FACIAL TREATMENT

PRE CONSULTATION FORM

Birthday - (Must be over the age of 18)
Day
Month
Year
Sex
Are you happy to allow us to store your data so we can contact you:

Compatibility Questionnaire.

If you answer yes for any one of the 11 questions below unfortunately we will not be able to offer you any Scar Therapy treatments at this time.

If you have any questions in regards to this please use the contact us page to get in touch.

1. Are you currently pregnant/breast feeding?
Yes
No
2. Have you ever developed keloids?
Yes
No
3. Have you had cancer or chemo therapy in the last 3 years?
Yes
No
4. Do you have a medical diagnosis for any of the following: Epilepsy, Anxiety, Stress, Depression?
Yes
No
5. Do you have a pacemaker or any major heart problems?
Yes
No
6. Do you suffer from any autoimmune disorders or other illnesses that affect the immune system?
Yes
No

For example: psoriasis, active eczema, lupus, vitiligo.

7. Do you have any infectious diseases ( HIV, AIDS, Hepatitis)
Yes
No
8. Are you currently or have you in the last 6 months finished a course of Accutane or Roaccutane?
Yes
No
9. Do you suffer from any blood diseases?
Yes
No

For example: Blood clots, Blood cancers, Hemophilia, Anaemia.

10. Do you suffer from Dermographic Urticaria/Dermographism?
Yes
No

Compatibility Questionnaire Part Two.

Please answer all of the questions below honestly to best of your knowledge. Don't worry if you answer yes to any of these questions, this doesn't mean you are ineligible for the treatment, we may just need some more information.

1. Do you take any prescribed medications on a regular basis?
Yes
No
2. Have you undergone any medical procedures in the last 30 days?
Yes
No

For example: Surgery, Laser therapy or any other medical intervention.

3. Are you planning to undergo any medical procedures between now and your treatment or within 30 days after?
Yes
No

For example: Surgery, Laser therapy or any other medical intervention.

4. Have you undergone any cosmetic procedures in the last 30 days?
Yes
No

For example: Tattoos, Tattoo/Pmu Removal, Chemical Peels or Retinol.

5. Are you planning to undergo any cosmetic procedures between now and your treatment or within 30 days after?
Yes
No

For example: Tattoos, Tattoo/Pmu Removal, Chemical Peels or Retinol.

6. Do you suffer from any heart related conditions or high blood pressure?
Yes
No
7. Do you suffer diabetes?
Yes
No
8. Have you had any Botox injections within the last 30 days?
Yes
No
9. Would you consider yourself above a number 3 on the Fitzpatrick scale?
Yes
No
10. Have you ever had an organ transplant in the past?
Yes
No

Once you have submitted your form please follow the instructions that appear below.

By submitting this form you are agreeing to our Terms & Conditions, Privacy Policy, and you agree to allow LADA Beauty to store your answers for a period of time to assist in the event of any future claims or legal proceedings.

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